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Physicians andThe Joint Commission:
The Patient Safety Partnership
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Part I: The role of the physicianin The Joint Commission
Part II: Focus on patient safety ―accreditation process, standards and performance measurement
Part III: Patient safety initiatives
Part IV: Enhancing physician involvement in quality and safety improvement initiatives
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Part I: The role of the physicianin The Joint Commission
Historical ties between physicians and The Joint Commission
Evolution of The Joint Commission The Joint Commission today
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Historical ties between physicians and The Joint Commission
1910 Ernest Codman, M.D., proposes the “end result system of hospital standardization.”
1913 American College of Surgeons is founded at the urging of Franklin Martin, M.D., a colleague of Dr. Codman. The “end result” system becomes an ACS stated objective.
1918 The ACS begins on-site inspections of hospitals. Only 89 of 692 hospitals surveyed meet the requirements of the Minimum Standard.
Ernest Codman, M.D.
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American College of Physicians American Hospital Association American Medical Association Canadian Medical Association
1951: The Joint Commission on Accreditation of Hospitals
The following organizations entered a “joint” agreement with the American College of Surgeons to create the Joint Commission on Accreditation of Hospitals, an independent, not-for-profit organization whose primary purpose was to provide voluntary accreditation.
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1959 The Canadian Medical Association withdraws to form its own accrediting organization.
1979 The American Dental Association becomes a JCAH corporate member.
1988 The name changes to the Joint Commission on Accreditation of Healthcare Organizations to reflect an expanded scope of activities.
The evolution continues…
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1999 The Joint Commission’s mission statement is revised to explicitly reference patient safety:
"To continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations."
Mission statement
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The name is changed to The Joint Commission. The new brand reflects The Joint Commission’s continuing efforts to improve the value of accreditation and its utility as a mechanism for improving the quality and safety of patient care.
A new mantra is adopted to reflect The Joint Commission’s commitment to the organizations it accredits and the public it serves: “Helping Health Care Organizations Help Patients”
The Joint Commission in 2007
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The Joint Commission accredits and certifies more than 15,000 health care organizations and programs in the United States.
The Joint Commission’s comprehensive accreditation process evaluates an organization’s compliance with state-of-the art standards, National Patient Safety Goals, and other accreditation requirements.
Joint Commission accreditation is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.
To earn and maintain The Joint Commission’s Gold Seal of Approval™, an organization must undergo an on-site survey or review by The Joint Commission at least every three years (every two years for laboratories).
The Joint Commission today
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General, psychiatric, children’s and rehabilitation hospitals Critical access hospitals Home health agencies, home medical equipment services,
hospice services and other home care organizations Nursing homes and other long term care facilities Behavioral health care organizations, addiction services Rehabilitation centers, group practices, office-based
surgeries and other ambulatory care providers Independent or freestanding laboratories
Accreditation
The Joint Commission provides evaluation and accreditation services for the following types of organizations:
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The Joint Commission awards Disease-Specific Care Certification to primary stroke centers, inpatient diabetes programs, chronic kidney disease programs, asthma management programs, and many other chronic disease programs.
The Joint Commission’s Health Care Staffing Services Certification Program recognizes excellence in supplemental staffing agency performance.
Transplant Center Certification provides national standards and recognition of exemplary performance for kidney, heart, lungs, liver and other transplant programs.
Health Care Services Certification focuses on improvement at the microsystem level for special services such as palliative care, physical rehabilitation, subacute care or wound care.
Certification
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The Board of Commissioners
Three ACS representatives Three ACP representatives One ADA representative Seven AMA representatives Seven AHA representatives Six public members One at-large nursing representative Joint Commission President Non-voting members represent Home Care, Long Term
Care and Behavioral Health Care
The Board consists of 29 individuals, including physicians, administrators, nurses, employers, a labor representative, quality experts, ethicists, consumer advocates and educators.
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Part II: Focus on patient safety ―accreditation process, standards and performance measurement
The Joint Commission’s mission is focused on continuously improving the safety and quality of care provided to the public.
The public is demanding more information about safety and quality of health care.
Physicians are a vital link in improving patient safety and delivering high quality health care.
The patient care experience is at the center of who we are and what we do
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May be asked to be a part of the organization’s team conducting the periodic performance review (mid-cycle assessment).
During the on-site survey, physicians may be interviewed as part of the patient tracer or system tracer activities to discuss their involvement in:
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Physician involvement in the accreditation process
National Patient Safety Goal compliance Universal Protocol for Preventing Wrong Site, Wrong
Procedure, Wrong Person Surgery ™ use Performance measurement activities
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Is continuous, data-driven and focuses on operational systems critical to the safety and quality of patient care.
At its most fundamental level, accreditation is a risk-reduction exercise.
Has undergone two major re-inventions that emanated from patient safety issues: the 1986 Agenda for Change project and the 2004 Shared Visions-New Pathways project.
Accreditation process
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“Joint Commission accreditation is a key predictor in the implementation of systems that promote patient safety by hospitals.”
“Accreditation status was the only organizational characteristic that consistently emerged in identifying which hospitals have more extensively implemented patient safety systems.”
“…The Joint Commission should continually strive to maintain evidence-based and state-of-the-art standards that advance the aim of providing the best possible care for hospitalized patients.”
(Longo et al, Journal of Healthcare Management, May/June 2007)
A recent study determined that:
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Patient safety-focused standards
More than 50 percent of standards are directly related to safety, addressing: medication use, infection control, surgery and anesthesia, transfusions, restraint and seclusion, staffing and staff competence, fire safety, medical equipment, emergency management, and security.
Include requirements for the response to adverse events; the prevention of accidental harm through the analysis and redesign of vulnerable patient systems (e.g., the ordering, preparation and dispensing of medications); and the organization’s responsibility to tell a patient about the outcomes of the care provided to the patient—whether good or bad.
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Developing new standards
New standards are added only when they will have a direct effect on the quality of care, or in response to environmental changes.
The Joint Commission seeks best evidence available Supported by well-designed studies Expert opinion
Recent examples of standards changes: Influenza immunization Emergency management Pharmacist review of medications in the ED
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Example 1: Medication Management
Look alike-sound alike drugs (15% of USP database) Illegible handwriting Similar labeling/packaging Incorrect drug selection from computerized list Wrong drug or dose especially high alert meds Drug interactions Lack of medication reconciliation Abbreviations, acronyms, symbols misunderstood Administered to wrong patient
Opportunities for error
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Using evidence-based good practices to develop medication processes (MM.6.10)
Monitoring medication management processes across the hospital to improve the medication management system (MM.8.10)
Handling all medications in the same manner, including sample medications (MM.2.10)
Reducing practice variation, errors and misuse (MM.5.10)
Medication Management standards MM.1.0-MM.8.10
A well-planned and implemented medication management system supports patient safety and improves the quality of care by:
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Example 2: Surveillance, Prevention and Control of Infection
Prevention of health care-associated infections represents one of the major safety initiatives a hospital can undertake.
CDC estimates that each year approximately two million patients acquire infections not related to their condition.
These infections result in about 90,000 deaths and add between $4.5 to $5.7 billion per year to patient care costs.
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Surveillance, Prevention and Control of Infection standards IC.1.10-IC.9.10
Establish a hospital-wide infection control program that identifies the risk for the acquisition and transmission of infectious agents (IC.1.10 and IC.2.10).
Incorporates relevant guidelines into the infection control and preventions activities (IC.4.10).
Offer influenza immunizations to staff and licensed independent practitioners (IC.4.15).
Evaluate the effectiveness of the program (IC.5.10). Be prepared to respond to an influx, or the risk of influx, of
infectious patients (IC.6.10).
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The goal of an effective IC program is to reduce the risk of acquisition and transmission of health care acquired infections. The hospital’s program should:
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Example 3: Credentialing and Privileging
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Determining the competency of practitioners to provide high quality, safe patient care is one of the most difficult decisions an organization can make.
The credentialing and privileging process collects, verifies andevaluates data relevant to a practitioner’s performance.
These activities serve as the foundation for objective, evidence-based decisions regarding appointment to the medical staff and the granting of privileges.
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Credentialing and Privileging standards MS.4.00-MS.5.10
The hospital collects information regarding each practitioner’s current license status, training, experience, competence and ability to perform the requested privilege (MS.4.10).
The decision to grant or deny privileges or to renew them is an objective, evidence-based process (MS.4.15).
The medical staff defines the circumstances requiring monitoring and evaluation of a practitioner’s professional practice (MS.4.30).
The medical staff provides the oversight for the quality of care, treatment and services by recommending members for appointment to the medical staff (MS. 4.60).
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Influencing patient safety standards ―Physician input
Traditional methods Expert panels Expert opinion Field reviews
• Electronic ― allows structured analysis• Written ― typically used by professional orgs
Newest method WikiHealthCare™
There are several ways that physicians influence the standards development process:
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WikiHealthCare™
A collaborative approach to the development of accreditation and certification standards.
Designed to enable and encourage discussion and collaboration among all users for the purpose of improving health care quality.
The Joint Commission provides the forum; users control the content.
Access it on the Joint Commission home page or go to http://wikihealthcare.jointcommission.org
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“By incorporating real ‘teeth’ into its patient safety standards as well as into its accreditation process, The Joint Commission provides the motivation for hospitals nationwide to follow its lead. This is a public trust that The Joint Commission must keep sacred.”
―Robert G. Kiely, FACHEPresident and CEO
Middlesex Health System
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The Joint Commission survey is patient-centered
Surveyors use the “tracer methodology” to assess the patient’s care experience and the organization’s system for providing care and services.
Surveyors retrace the specific care processes that the patient experienced by observing and talking to staff, including physicians, in areas that the patient received care.
The tracer activity provides opportunities to provide education to organization staff and leaders, as well as, to share best practices from other health care organizations.
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Throughout the survey, physician participation is critically important to evaluating the quality of the care, treatment and
services that the patient received.
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The Joint Commission survey is systems-focused
Surveyors conduct “systems tracers” to analyze key operational systems that directly affect the quality and safety of patient care.
System tracers involve discussion and education about the use of data in performance improvement (as in core measure performance and the analysis of staffing), medication management, infection control, emergency management and other current topics of interest to the organization.
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Benefits of the survey process
Surveyors concentrate on the issues most important to each organization surveyed.
The survey process is customized to the organization’s settings, services, patient population and demographics.
The process focuses on the delivery of care (guided by the Priority Focus Process and tracer methodology).
Less paperwork and burden of preparing documentation for survey because surveys are unannounced.
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Performance measurement
During the on-site survey, surveyors assess organizations’ use of measures in their performance improvement activities.
For hospitals, The Joint Commission also collects data on standardized or “core” performance measures.
The Joint Commission is working with CMS to align current and future core measures.
Currently, measures for heart attack, heart failure, pneumonia and surgical care are aligned.
Performance measurement was first introduced into the accreditation process in 1997. The ORYX Initiative allows The Joint Commission to review data trends and to work with organizations as they use data to improve patient care.
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Providing performance data to the public
Portrays aggregate performance of accredited American hospitals against the standardized national performance measures and the National Patient Safety Goals.
Is part of ongoing efforts to emphasize the importance of accountability in health care and continuous improvement for hospitals.
Empowers consumers with information to make them more active participants in their health care.
Improving America’s Hospitals is an annual report first published in 2006, which focuses on the quality of care provided to patients with heart attacks, heart failure, pneumonia and surgical conditions.
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Performance measurement activities have improved the quality of care
Examined hospital performance on 18 standardized indicators of the quality of care for acute myocardial infarction, heart failure and pneumonia
Data was collected during a two-year period in 3,000 accredited hospitals.
Descriptive analysis revealed a significant improvement (P<0.01) in the performance of the hospitals on 15 of 18 measures. The magnitude of improvement ranged from three to 33 percent during the eight quarters studied.
(Williams, Loeb et al, The New England Journal of Medicine, July 21, 2005)
Article in The New England Journal of Medicine, “Quality of Care in US Hospitals as reflected by Standardized Measures, 2002-2004:”
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“Public reporting of standardized measures of quality has become an important component of quality improvement activities at national and local levels.
…other characteristics of hospitals, including ownership, teaching status, JCAHO accreditation, and investments in technology and nursing, were also strongly related to performance, and these characteristics are often remediable and can be used to influence patient choice.”
(Landon et al, Archives of Internal Medicine, 2006; 166)
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Part III: Patient Safety Initiatives
Sentinel Event Policy Sentinel Event Alerts Sentinel Event Advisory Group National Patient Safety Goals National Patient Safety Summits: Wrong Site Surgery,
Medical Abbreviations, Medication Reconciliation The Universal Protocol™
In addition to the standards, The Joint Commission demonstrates its commitment to patient safety through:
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Sentinel Event Policy
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. “Sentinel" because they signal the need for immediate investigation and response.
The Sentinel Event Policy, implemented in 1996, is designed to help health care organizations identify sentinel events and takeaction to prevent their recurrence.
Any time a sentinel event occurs, the health care organization completes a root cause analysis, implements improvements to reduce risk, and monitors the effectiveness of those improvements.
The Joint Commission shares de-identified, aggregate information about sentinel events at: www.jointcommission.org/SentinelEvents/Statistics
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Sentinel Event experience
531 events of wrong site surgery520 inpatient suicides488 operative/post op complications385 events relating to medication errors302 deaths related to delay in treatment224 patient falls153 deaths of patients in restraints138 assault/rape/homicide125 perinatal death/injury94 transfusion-related events85 infection-related events72 deaths following elopement66 fires67 anesthesia-related events51 retained foreign objects
763 “other”
Of 4,064 sentinel events reviewed by the Joint Commission, January 1995 through December 2006:
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Settings of Sentinel Events
0 500 1000 1500 2000 2500 3000
Health care networkOffice-base surgery
Critical access hospitalClinical laboratoryHome care service
Ambulatory care settingLong term care facilityEmergency department
Psychiatric unitNon-acute behavioral hlth
Psychiatric hospitalGeneral hospital
Total for all settings = 4064
2760443
204
186
159
116
102
78
6
3
2
5
January 1995 through December 2006
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Root causes of Sentinel Events
17
1711
4935
4234
31
6532
5114
0 10 20 30 40 50 60 70 80 90 100
Organization culture
Care planning
Continuum of care
Leadership
Environ. safety / security
Procedural compliance
Competency/credentialing
Availability of info
Staffing
Patient assessment
Orientation/training
Communication
Percent of 516 events
Average number of root causes cited
per RCA = 5.3
(all categories 2006)
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Sentinel Event Alert A newsletter that identifies specific types of sentinel events,
describes their common underlying causes, and recommends steps to prevent occurrences in the future.
Information comes mainly from The Joint Commission’s sentinel event database, experts and other organizations.
Shares important “lessons learned” and provides important information relating to the occurrence and management of sentinel events.
Raises awareness in the health care community and the federal government about the occurrence of adverse events and ways they can be prevented.
Topics have included medication errors, wrong-site surgery, restraint-related deaths, blood transfusion errors, inpatient suicides, infant abductions, fatal falls and operative/post-operative complications.
38 Alerts have been issued since 1998.
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Sentinel Event Advisory Group
Appointed in 2002, this group of experienced physicians, nurses, pharmacists and other patient safety experts advises The Joint Commission in the development of its National Patient Safety Goals.
Conducts thorough reviews of all Sentinel Event Alertrecommendations and identifies those that are candidates for inclusion in the annual NPSGs.
Advises The Joint Commission as to NPSG face validity, practicality and implementation cost.
Aligns potential NPSGs with the requirements of other organizations, such as the National Quality Forum and the Leapfrog Group, to the extent possible.
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National Patient Safety Goals
In July 2002, The Joint Commission approved the first set of six NPSGs with 11 related requirements for hospitals.
In 2004, program-specific NPSGs were developed for all programs.
NPSGs promote specific improvements in patient safety. All Joint Commission accredited health care organizations
are surveyed for implementation of the Goals and Requirements—or acceptable alternatives—as appropriate to the services the organization provides.
Each year, new recommendations are considered from Sentinel Event Alert and other sources.
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2008 National Patient Safety Goals Patient identification Communication among caregivers Medication safety Health care-associated infections Medication reconciliation Patient falls Flu & pneumonia immunization Surgical fires Patient involvement Pressure ulcers Focused risk assessment (suicide, home fires) Rapid response to changes in patient condition Universal Protocol for Preventing Wrong Site Surgery™
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National Patient Safety GoalsNon-Compliance Rates ― Hospitals
15.2%8.9%Label meds and solutions3D
6.4%7.4%2.4%Look-alike/sound-alike drugs3C
5.8%6.1%Hand-off communication2E
35.8%26.9%9.5%Report critical test results2C
36.1%36.9%38.6%24.8%23.5%“Do not use” abbreviations2B
5.5%15.7%12.3%8.2%7.4%Read back verbal orders2A
21.2%25.8%17.3%8.0%8.9%“Time-out” before surgery (U.P.)1B
3.9%8.1%4.7%4.1%3.8%Two patient identifiers1A
3301,4291,5731,5281,249Full SurveysNPSG
2007*2006200520042003Year
*First quarter 2007
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National Patient Safety GoalsNon-Compliance Rates ― Hospitals
*First quarter 2007
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18.5%27.5%0.3%Transfer/discharge reconciliation8B
18.2%33.9%0.1%Medication list & recognition8A
6.4%8.8%3.6%1.2%CDC hand hygiene guidelines7A
4.8%6.6%3.3%4.6%6.2%Surgical site marketing (U.P.)4B
0.3%2.9%4.5%5.4%1.5%Pre-op verification process (U.P.)4A
3301,4291,5731,5281,249Full SurveysNPSG
20072006200520042003Year
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“Prior to JCAHO’s safety goal requiring read-backs of patient names and oral orders, virtually no American hospital had a strict policy mandating this commonsensical redundancy, despite the fact that many restaurants have long performed read-backs to avoid errors in processing take out orders.”
(Wachter, Health Affairs, November 2004)
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National Patient Safety Summits
Medical Abbreviations Summit Wrong Site Surgery Summits Medication Reconciliation Summit
The Joint Commission convenes national meetings of experts and representatives of professional organizations, including physicians, to review pressing issues affecting patient safety, and to make recommendations.
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Medical Abbreviations Summit
November 2004 To gain consensus on:
Is there a problem? What is the evidence? Where is the problem? Which documents? Should there be a universal “do not use” list? What should be on the list? Should there be any exemptions? How can a “do not use” requirement be
effectively implemented? What is a reasonable expectation for
compliance? How does this become a “natural” behavior?
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Recommendations from the Summit
Continue nationally standardized “do not use” list Also consider prohibiting: “>” and “<“ Abbreviations and acronyms for any drug
names R and L Apothecary units@ cc μg
No additions for 2008
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Official “Do Not Use” List1
1 Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms.*Exception: A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.
Write “morphine sulfate”
Write “magnesium sulfate”
Can mean morphine sulfate or magnesium sulfateConfused for one another
MS
MSO4 and MgSO4
Write X mgWrite O.X mg
Decimal point is missedTrailing zero (X.0 mg)*Lack of leading zero .X mg)
Write “daily”Write “every other day”
Mistaken for each otherPeriod after the Q mistaken for “I” and the “O” mistaken for “I”
Q.D., QD, q.d., qd (daily) Q.O.D., QOD, q.o.d., qod(every other day)
Write “International Unit”Mistaken for IV (intravenous) or the number 10 (ten)
IU (International Unit)
Write “unit”Mistaken for “0” (zero), the number “4” (four) or “cc”
U (unit)
Use insteadPotential problemDo not use
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Wrong Site Surgery Summits
In 2003, The Joint Commission hosted the first Wrong Site Surgery Summit with the goal of obtaining consensus on the adoption of a “universal protocol”for preventing wrong site, wrong procedure and wrong person surgery.
Participants agreed that: A universal protocol would help prevent the
occurrence of wrong site, wrong procedure and wrong person surgery.
The protocol should be specific, so as to eliminate confusion about site marking and facilitate communication among surgical team members.
It should provide the flexibility needed for unique surgical situations.
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Universal Protocol Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery ™
Effective in January 2004. Created to address the continuing occurrence of medical
errors. Applies to all operative and other invasive procedures. The
components include: Pre-operative verification process. Marking of the operative site. Taking a ‘time out’ immediately before starting the
procedure. Adaptation of the requirements to non-operating room
settings, including bedside procedures. Endorsed by more than 50 professional health care
associations and organizations.
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Wrong Site Surgery Summits, cont.
The follow-up Summit in 2007: Reviewed experience with the Universal Protocol. Examined the barriers to achieving consistent
compliance with the performance expectations set forth in the Universal Protocol.
Explored other potential strategies for eliminating wrong site surgery.
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Sentinel Event trends: Wrong-site surgeries reported by year
0
10
20
30
40
50
60
70
80
90
100
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
S. E. Alert # 6August 1998
W.S.S. Summit IMay 2003
S. E. Alert #24December 2001
NPSGsJanuary 2003 U.P.
W.S.S. Summit IIFebruary 2007
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Medication Reconciliation Summit
Held in September 2007. Participants discussed the challenges associated with
reconciling medications in various health care settings. The consensus of the Summit was that the process of
medication reconciliation—obtaining an accurate medication list from the patient and assuring its accuracy throughout the care continuum—improves patient safety.
A document outlining the suggestions of the attendees and next steps is being developed.
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Looking forward to 2009Topics under consideration for the 2009 National Patient Safety Goals:
Elimination of transfusion errors
Prevention of multiple drug resistant organism infections
Prevention of catheter-associated blood stream infections
Prevention of surgical site infections
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“…A recent survey of hospital leaders felt that the JCAHO was the most important driver of progress in patient safety.”
(Devers, Pham, Liu, “What is driving hospital patient safety efforts?” Health Affairs 23, 2004)
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Part IV: Enhancing physician involvement in quality and safety improvement initiatives The Joint Commission’s Board of Commissioners has
identified enhancing physician engagement in accreditation and other quality improvement initiatives as one of its top strategic priorities.
With an ability to serve as a bridge between patients and staff and staff and management, physicians play a unique leadership role in fostering improvements in care.
Physician leadership and involvement are critically important to the success of The Joint Commission’s patient safety improvement efforts, including:
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Standards review National Patient Safety Goals Health care summits Sentinel Event Alert topics
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Physician Engagement Advisory Group
Established in 2005. Advises The Joint Commission on expanding
physician participation in the accreditation process and broadening physician engagement in quality of care and patient safety initiatives.
Members include physician quality directors and educators, chief medical officers, private practice physicians and other physician leaders from urban and rural areas.
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Public Policy Action Plan
Convening roundtables with experts and stakeholders who are knowledgeable about and affected by the issue. The role of the roundtables is to synthesize the problem and frame potential solutions and accountabilities.
Developing white papers that include the prominent elements of the roundtable discussion.
Holding national symposia that permit in-depth exploration of important aspects of the problem and the solutions.
Conducting follow-up regional summits or other activities to maintain the visibility of the issue and facilitate pursuit of its resolution.
The Joint Commission’s Public Policy Action Plan focuses on key areas related to patient safety and health care quality. In approaching these issues, The Joint Commission relies heavily onphysician input when:
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Current public policy initiatives Development of a National Performance Data
Management Strategy Emergency Department Overcrowding Emergency Preparedness Health Care Professional Education Health Literacy and Patient Safety Hospital of the Future Nurse Staffing Crisis Organ Donation Tort Resolution and Injury Prevention
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For more information about any of these topics, visit www.jointcommission.org
Sign up to receive physician-specific information.
Sign up for other Joint Commission info.
Joint Commission International Centerfor Patient Safety
Receive notification of field reviews and other news andevents.
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